Mrs. Port Case Summary

An 85-year-old female who says that she has been doing relatively good. Memory is a little more problematic, and she has some neuropsychiatric testing lined up for next week. She is breathing good. No chest pain. Notes a little bit of peripheral edema from time to time. Appetite good. She says she is eating too much. Her glucose machine broke, and she has not been monitoring her sugars. Her rheumatoid arthritis is doing quite well, and responded to an increase in methotrexate. She says her rheumatologist does not feel that she needs to come back to him anymore. Lab work is out of date, and we will fix that today.

M. H. states that she is generally in good overall health. No cardiac, respiratory, endocrine, vascular, musculoskeletal, urinary, hematologic, neurologic, genitourinary, or gastrointestinal problems.

She has a medical history of severe RA, had an upper gastrointestinal bleed in 1993, and had coronary artery disease with a coronary artery bypass graft (CABG) 9 months ago. She lives alone but has three children whom live close to her. She is a widow and her father died of cancer at 62 years old and mother died from heart failure at 79 years old. She has a 50-pack-year smoking history but denies alcohol use. Ever since her CABG she has engaged in “very mild exercises at home.” Her medications are Rabeprazole (Aciphex) 20mg/day, Prednisone (Deltasone) 5 mg/day PO and Methotrexate (Amethopterin) 2.5 mg/week.

My patient is a 58-year-old female, who presents with controlled type II diabetes, hypertension, and possibly thyroid tumors that have been there for a few years. She is under the care of a physician for her diabetes and associated controlled hypertension. I recommended several times that she see her physician after feeling the tumors around her neck and thyroid. Her medical history also indicates that she had rheumatic fever twelve to thirteen years ago, has arthritis in her knees, and occasional headaches. She is 5”3 and weighs 216 pounds. Her blood pressure was 126/80, pulse was 88 BPM, respirations were 20, and her temperature was 98.2 Fahrenheit. She doesn’t smoke and I made sure that she had eaten lunch and wasn’t hungry. She is currently on 100 mg Metformin for her diabetes, 120 mg. Lisinopril for hypertension, 40 mg. of Lovastatin to lower cholesterol, 80 mg. of Aspirin to prevent cardiovascular disease, and daily insulin. Reviewing her medical HX, I was informed that she usually checks her blood glucose daily, but had recently run out of strips, so it had been a

She converses appropriately. Blood pressure 92/60 supine. Blood pressure decreased to 72/50 standing. Pulse is 90 and regular. Weight 113 pounds. She has a normal appearance of her face and does not have a masked appearance of her face. She has good strength throughout her face. She has good strength of her extremities. She has only minimal cogwheel rigidity at the left wrist, but no cogwheel rigidity at the right wrist. She has no tremor of her hands. She moves her extremities freely and with normal speed. She is able to rise on her own from a sitting to a standing position, only minimal bradykinesia of standing. She walks fairly freely and there is a normal cadence of her gait. She did not have dyskinetic movements of her extremities. She is able to walk, including turning without losing her balance. She does not shuffle her feet when walking. She does not have en bloc turning. She has good posture stability

May 18th 2014 Mr. Beaird fell and broke his hip. This followed hip surgery performed by Dr. Baker and 21 day rehabilitation form Cordova NH. Before his 21 days was up Mr. Beaird tried to break out of NH by running his scooter though the front door at the NH. When the scooter hit the door, the door opened and Mr. Beaird rolled onto the front porch during this altercation, his foot was injured and the ambulance was called. Mr. Beaird was admitted to Senior Care and diagnosed with a

A review of her medical record indicates that she has a history of functional decline, dementia, weakness, MRSA, cognitive communication deficit, presence of right artificial hip joint and HTN.

MEDICAL UPDATE: Client continues to report arthritis in her left leg and hand, high blood pressure. She also reports she will need surgery but she is waiting to be housed.

She reports a history of back pain, ovarian cysts excision, and breast tumor. She denies chest pain, shortness of breath, or palpitations. Patient reports that her immunizations and preventive care are up to

1. Client does not like western medicine; she prefers homeopathic remedies to medications and exhibits distrust of some medications. She takes her insulin daily because she thinks it does not harm her body because her body makes it. However she believes that even with the severity of her pain

Per medical records (2008-2014), the claimant had a history of multiple medical issues, including migraines, right hand tremors, alcohol abuse, obesity, gastro-esophageal reflux disease (GERD), nausea, abdominal pain, endometriosis and degenerative changes in the left knee. In 2014, she was evaluated for hip

At today’s visit she is accompanied by her husband and private aide. Her husband reports that she is doing much better. He states that her pain has improved and she has not taken her pain medication since last visit. He states that her anxiety had improved extremely with the recent change in her Xanax. He states that he has hired 24 help for the patient and since she has not fallen. She reports that she is feeling well. The caregiver reports that the patient continue to suffers from hypotension and hypertension with variation in blood pressure. The patient also continues to suffer from chronic tremors as a result of her Parkinson.

A 79-year-old female present with her daughter for ongoing fatigue also noted to have lost 5 pounds over past 6 months. No night sweats or fevers. Pertinent past medical history includes severe, generalized osteoarthritis, hypertension, type 2 diabetes mellitus and depression. She is taking the following medications: acetaminophen 650mg every eight hours, Lyrica 75 mg twice daily; alendronate 70 mg once weekly, valsartan 320 mg once daily, fluoxetine 40mg once daily and insulin glargine 20 units once daily. Your exam reveals slight pale conjunctivae, a 2/6 systolic ejection murmur and generalized arthritic joints in her extremities. A point of care test results in a hemoglobin of 10.2 g/dL. Complete blood cell count is done; results

At todays visit she is accompanied by her husband. She is awake, alert and oriented. She complains of chronic pain in her hips and legs that radiate down to her feet. She describes her pain as as shooting, dull, ache. “she states, sometimes its like

At today’s visit she is seen at Tiffany hall SNF. She is found in her room. She is awake and alert and oriented. She c/o of pain in her hips and knees, that she describe as achy with a severity of 5/10, the pain does not radiate but does affect her ability to ambulate, she is using a wheelchair. Her pain regimen is Lortab 7.5 mg p.o every 4 hours. She reports that she has increased hip pain when she sleeps on her mattress because she sinks in her mattress. She is schedule to follow up with her orthopedic doctor Dr. Shute.